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- Multiple inherited thrombophilias in a young patient with striatocapsular strokePublication . Taveira, Isabel; Vicente, Claudia; Sobrall, Sofia; Nzwalo, Hipolito; Sousa E Costa, Jose
- Late hospital arrival for thrombolysis after stroke in Southern Portugal: Who is at risk?Publication . Sobral, Sofia; Taveira, Isabel; Seixas, Rui; Vicente, Ana Claudia; Duarte, Josiana; Goes, Ana Teresa; Duran, David; Lopes, Joao; Rita, Henrique; Nzwalo, HipĆ³litoBackground: Delayed hospital arrival remains the main reason for the low rates of thrombolysis in eligible acute ischemic stroke (AIS) patients. The role of socioeconomic and clinical factors for the prehospital delay of AIS remains poor and has never been studied in Portugal. Objectives: Describe the socioeconomic and clinical factors leading to delayed hospital admission of AIS patients eligible to thrombolysis. Methods: A case-control study with a consecutive thrombolyzed AIS patients from 2010 to 2015. Controls were patients who did not receive thrombolysis because of late hospital arrival. Logistic regression with stepwise forward regression analysis was used to identify independent predictors of delayed admission to receive thrombolysis with intravenous tissue-type plasminogen activator (rtPA). Results: Of the 1247 patients admitted with AIS, 76 (6%) arrived on-time and received intravenous rtPA. Controls were 65.8% (146/222) of the total number of patients included in the study. Overall, the mean age was 73 years (+/- 11, 61), a minority were below 60 years, and 43.7% were women. Being beneficiary of social insertion income (odds ratio [OR]: .286; .124-.662, P = .003), not having any telephone contact (OR: .145; .039-.536, .004) or having exclusive landline (.055; .014-.210, < .001) and posterior circulation stroke (OR: .266; .087-.811, P = .020) decreased the likelihood of hospital arrive on-time rtPA. The use of prehospital ambulance services increased (OR: 6.478; 2.751-15.254, P < .001) the odds of ER on-time arrival for thrombolysis. Conclusions: Poverty, lack of stroke awareness, or difficulties in requesting immediate medical help are the main factors implicated in late-hospital admission for thrombolysis in AIS. Stroke awareness campaigns, promotion of activation of national emergency number and stroke code can increase the rate of thrombolysis.
- 24-hour rhythmicity of seizures in refractory focal epilepsyPublication . Nzwalo, HipĆ³lito; Cordeiro, InĆŖs Menezes; Santos, Ana Catarina; Peralta, Rita; Paiva, Teresa; Bentes, CarlaThe occurrence of seizures in specific types of epilepsies can follow a 24-hour nonuniform or nonrandom pattern. We described the 24-hour pattern of clinical seizures in patients with focal refractory epilepsy who underwent video-electroencephalography monitoring. Only patients who were candidates for epilepsy surgery with an unequivocal seizure focus were included in the study. A total of 544 seizures from 123 consecutive patients were analyzed. Specific time of seizures were distributed along 3- or 4-hour time blocks or bins throughout the 24-hour period. The mean age of the subjects was 37.7 years, with standard deviation of 11.5 years, median of 37. The majority were females (70/56%). The majority of patients had a seizure focus located in the mesial temporal lobe (102/83%) and in the neocortical temporal lobe (13/11%). The remaining patients had a seizure focus located in the extratemporal lobe (8/6%). The most common etiology was mesial temporal sclerosis (86/69.9%). Nonuniform seizure distribution was observed in seizures arising from the temporal lobe (mesial temporal lobe and neocortical temporal lobe), with two peaks found in both 3- and 4-hour bins: 10:00-13:00/16:00-19:00 and 08:00-12:00/16:00-20:00 respectively (p = 0.004). No specific 24-hour pattern was identified in seizures from extratemporal location. The 24-hour rhythmicity of seizure distribution is recognized in certain types of epilepsy, but studies on the topic are scarce. Their replication and validation is therefore needed. Our study confirms the bimodal pattern of temporal lobe epilepsy independently of the nature of the lesion. However, peak times differ between different studies, suggesting that the ambient, rhythmic exogenous factors or environmental/social zeitgebers, may modulate the 24-hour rhythmicity of seizures. Characterization of these 24-hour patterns of seizure occurrence can influence diagnosis and treatment in selected types of epilepsy, such as the case of temporal lobe epilepsy, the most common drug-resistant epilepsy. (C) 2015 Elsevier Inc. All rights reserved.
- Clinicoepidemiological profile of cerebral venous thrombosis in Algarve, Portugal: a retrospective observational studyPublication . Nzwalo, HipĆ³lito; Rodrigues, Fatima; Carneiro, Patricia; Macedo, Ana; Ferreira, Fatima; Basilio, CarlosBackground: Cerebral venous thrombosis (CVT) is a very uncommon disorder with a wide variety of clinical manifestations. There are few studies describing the clinical and epidemiological profile of CVT in peripheral or rural areas. Over the last decades, the frequency in which this disease is diagnosed has increased due to greater awareness and availability of noninvasive diagnostic techniques. Materials and Methods: A hospital-based retrospective case review of adult (>= 15 years) patients with CVT between 2001 and 2012 is described. 31 patients with confirmed imagiological diagnosis of CVT were included. Statistical Analysis Used: Statistical analysis was performed using R version 2.15.2. Incidence rate was computed as number of new cases by time. Confidence interval (CI) was set at 95% and P < 0.05 was considered significant. Results: The average annual incidence was 0.84 (CI: 0.58-1.18) to 0.73 (CI: 0.5-1.02) per 100 000 cases for adult population. There were 23 (74%) women and 8 (26%) men. Predominant initial manifestations were headache, followed by altered mental status and seizures. Median diagnostic delay from onset of illness was 8 days. All patients were treated with unfractionated heparin or low-molecular heparin followed by warfarin. Complete recovery occurred in the majority of cases 22 (78.6%) but two patients died during hospitalization. Conclusions: Albeit with some particularities, the epidemiology and clinical manifestations we found are comparable to what has been reported in western studies.
- On the pathways of an imperfect chameleon: posterior reversible encephalopathy syndromePublication . FĆ©lix, Catarina; Nunes, NĆ”dia; FlorĆŖncio, AndrĆ©; Grande, Pablo; Gozabez, Beatriz; Milheiro, Miguel; Soleiro, Luis; Shamasha, Motassen; Nzwalo, HipĆ³litoPosterior reversible encephalopathy (PRES) is a rare clinicoradiological syndrome characterized by a variety of neurological manifestations such as acute encephalopathy, headache, seizures, visual loss, and focal neurologic signs in association with a reversible and predominantly posterior leukoencephalopathy [1,2]. Although precipitated by severe hypertension in most cases, other conditions such as eclampsia, autoimmune disorders, renal failure, and drugs, for example, are now recognized to cause PRES [3]. The number of publications of PRES in the last years reļ¬ects the increasing recognition of the syndrome and also the availability of brain magnetic resonance (brain MRI) for urgent or emergency situations. However, because of its pleotropic clinical and radiological manifestations, the possibility of misdiagnosis should be considered [4]. Therefore, we decided to review and discuss our clinical experience in the diagnosis and management of this rare entity.
- Acute stroke with concomitant acute myocardial infarction: will you thrombolyse?Publication . Maciel, Rita; Palma, Raquel; Sousa, Pedro; Ferreira, Fatima; Nzwalo, HipĆ³litoConcomitant occurrence of acute myocardial infarction (MI) and stroke is infrequently encountered in emergent patients. Acute MI within the previous 3 months is considered a relative contraindication for therapy with alteplase or intravenous tissue plasminogen activator (IV rtPA).1 The use of IV rtPA for stroke in patients with a recent MI is associated with an increased risk of cardiac rupture, secondary to breakdown of the existing fibrin clot within the necrotic myocardium and/or degradation of collagen2 . Whether it is appropriate to perform thrombolysis in an emergent patient with concomitant ischemic stroke and MI remains a matter for debate.
- IgG4: related disease presenting with headache and papilloedemaPublication . LourenƧo, Eva PatrĆcia; Nzwalo, HipĆ³lito; Sampaio, MĆ”rio Rui; Afonso, LuĆsA previously healthy man aged 57years presented with a 4-week duration of predominant decubitus daily holocranial headache after minor head injury. Apart from unintentional weight loss of 8 pounds, there were no associated constitutional or systemic manifestations.The generalandneurologicalexamination was unremarkable. The funduscopy showed bilateral grade 2 papilloedema. Brain magnetic resonance (MRI) ļ¬ndings are shown in ļ¬gure 1AāE. The brain MRI showed the presence of diffuse dural thickening (ļ¬gure 1BāE) hypointense on unenhanced T1 imaging (ļ¬gure 1BāF), with dural enhancement on T1-weighed imaging (ļ¬gure 1BāF). The opening cerebrospinal ļ¬uid (CSF) pressure was 380mm Hg. With the exception of serum-elevated IgG4 immunoglobulin (IgG4=302 mg/dL) and elevated CSF protein level (68 mg/dL), the wide and extensive complementary study including body positron emission tomography scan, laboratory blood/CSF work-up was negative, excluding neoplastic, infectious, autoimmune and collagen vascular disorders. Meningeal biopsy showed ļ¬brous thickening with moderate and predominant B and T cells inļ¬ammatory inļ¬ltrate. The patient improved with spinal taps evacuation and methylprednisolone treatment. Intracranial hypertrophic pachymeningitis is a severe and rare manifestation in the spectrum of IgG4-related diseases.12Biopsy of meninges is the gold standard for the diagnosis.3 Exclusion of systemic inļ¬ammatory disorders and demonstration elevated serum IgG4 can support the diagnosis in patients with typical diffuse dural thickening.13The disease respondsto immunosuppressive drugs such as corticosteroids, methotrexate, azathioprine, mycophenolate or cyclophosphamide.12Mass effect due to dural thickening can cause progressive neurological debilitation,blindness and cerebellarataxia.In the case of symptomatic hydrocephalus, surgical exploration for decompression maybe required
- Hypoalbuminemia, systemic inflammatory response syndrome, and functional outcome in intracerebral hemorrhagePublication . Di Napoli, Mario; Behrouz, Reza; Topel, Christopher H.; Misra, Vivek; Pomero, Fulvio; Giraudo, Alessia; Pennati, Paolo; Masotti, Luca; Schreuder, Floris H. B. M.; Staals, Julie; Klijn, Catharina J. M.; Smith, Craig J.; Parry-Jones, Adrian R.; Slevin, Mark A.; Silver, Brian; Willey, Joshua Z.; Azarpazhooh, Mahmoud R.; Vallejo, Jaime Masjuan; Nzwalo, HipĆ³lito; Popa-Wagner, Aurel; Godoy, Daniel A.Purpose: Hypoalbuminemia and systemic inflammatory response syndrome (SIRS) are reported in critically-ill patients, but their relationship is unclear. We sought to determine the association of admission serum albumin and SIRS with outcomes in patients with intracerebral hemorrhage (ICH). Methods: We used a multicenter, multinational registry of ICH patients to select patients in whom SIRS parameters and serum albumin levels had been determined on admission. Hypoalbuminemia was defined as the lowest standardized quartile of albumin; SIRS according to standard criteria. Primary outcomes were modified Rankin Scale (mRS) at discharge and in-hospital mortality. Regression models were used to assess for the association of hypoalbuminemia and SIRS with discharge mRS and in-hospital mortality. Results: Of 761 ICH patients included in the registry 518 met inclusion criteria; 129 (25%) met SIRS criteria on admission. Hypoalbuminemia was more frequent in patients with SIRS (42% versus 19%; p < 0.001). SIRS was associated with worse outcomes (OR: 4.68, 95% CI, 2.52-8.76) and in-hospital all-cause mortality (OR: 2.18, 95% CI, 1.60-2.97), while hypoalbuminemia was not associated with all-cause mortality. Conclusions: In patients with ICH, hypoalbuminemia is strongly associated with SIRS. SIRS, but not hypoalbuminemia, predicts poor outcome at discharge. Recognizing and managing SIRS early may prevent death or disability in ICH patients.
- Pilocytic astrocytomaPublication . LourenƧo, Eva PatrĆcia; Nzwalo, HipĆ³lito; Sampaio, MĆ”rio Rui; Varela, Ana VerĆ³nicaPilocytic astrocytoma (PA) is a benign tumour of childhood, often located in deep midline structures such as the brainstem and the cerebellum.1 Gross surgical resection is curative in the majority of patients.2 We report a case of recurrent PA diagnosed after an acute confusional state and rightsided spastic hemiparesis in a previously healthy 38-year-old woman. Her initial brain CT showed a left temporal mass causing obstructive hydrocephalus (ļ¬gure 1AāC). Acute surgical extraction was performed (ļ¬gure 1D) and the biopsy conļ¬rmed the diagnosis of PA grade I (WHO). The patient remained clinically asymptomatic for 1 year, when a progressive headache emerged. At this time, the neurological examination disclosed the presence of dysarthria and right-sided hemiparesis with facial involvement. Brain MRI showed the presence of recurrent PA (ļ¬gure 1E, F). The patient again underwent surgery due to the mass effect and brainstem compression caused by the tumour, and the diagnosis of PA was reconļ¬rmed histologically. The patient fully recovered after the intervention. PA occurs commonly in the ļ¬rst 2 decades of life.1 Information on the characteristics of PA in adulthood is scarce due to its rarity. Some studies indicate the adult prognosis to be similar to that in children, while others indicate that PA may show aggressive behaviour with tumour recurrence and death.2 Anaplastic features are associated with worse prognosis, but little is known about the value of genetic characterisation in adulthood PA.3 In conclusion, this case offers a unique description of adult onset PA in an atypical location outside the midline structures, and also provides an example of early recurrence.
- Intracerebral hemorrhage as a manifestation of cerebral hyperperfusion syndrome after carotid revascularization: systematic review and meta-analysisPublication . Abreu, Pedro; Nogueira, Jerina; Rodrigues, Filipe Brogueira; Nascimento, Ana; Carvalho, Mariana; Marreiros, Ana; Nzwalo, HipĆ³litoIntracerebral hemorrhage (ICH) in the context of cerebral hyperperfusion syndrome (CHS) is an uncommon but potentially lethal complication after carotid revascularization for carotid occlusive disease. Information about its incidence, risk factors and fatality is scarce. Therefore, we aimed to perform a systematic review and meta-analysis focusing on the incidence, risk factors and outcomes of ICH in the context of CHS after carotid revascularization. We searched the PubMed and EBSCO hosts for all studies published in English about CHS in the context of carotid revascularization. Two reviewers independently assessed each study for eligibility based on predefined criteria. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed, and the PROSPERO register was made (register no. CRD42016033190), including the pre-specified protocol. Forty-one studies involving 28,956 participants were deemed eligible and included in our analysis. The overall quality of the included studies was fair. The pooled frequency of ICH in the context of CHS was 38% (95% CI: 26% to 51%, I2 = 84%, 24 studies), and the pooled case fatality of ICH after CHS was 51% (95% CI: 32% to 71%, I2 = 77%, 17 studies). When comparing carotid angioplasty with stenting (CAS) with carotid endarterectomy (CEA), post-procedural ICH in the context of CHS was less frequent in CEA. ICH following CHS occurred less often in large series and was rare in asymptomatic patients. The most common risk factors were periprocedural hypertension and ipsilateral severe stenosis. ICH as a manifestation of CHS is rare, more frequent after CAS and associated with poor prognosis. Periprocedural control of hypertension can reduce its occurrence.